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05/18/2013 Name Withheld
Painful Bunion in a 12 Year Old
Thank you all to those that gave me your input. I did not provide an extensive biomechanical exam with my first presentation. This patient has at least 10 degrees of ankle dorsiflexion with her knee extended or flexed. Her hamstrings are not tight. She has symmetrical hip motion more with no internal position. There is no internal tibial torsion. She does not have ligamentous laxity. Her first ray is stable on exam. She is only moderately pronated in stance and gait. Her lateral x-ray does not have an anterior break in the cyma line. There is no Kirby's sign. There is no elevation of 1st ray (Seeberg's index).
She has noticed the bunions for several years, and has had moderate aching in the joint for the past year. She is a serous athlete. Although she is only 12, she has reached menarche and her appearance is that of several years older. I tell all my patients that these are progressive deformities and that there is a high rate of reoccurrence, especially in a young patient. I always recommend orthotics, both before and after a surgical approach.
On radiographs her growth plates are almost closed. I suspect there is very little additional length of her metatarsals to come. I do not believe that she will "escape" surgery in her life time. Perhaps if not surgery this year than next. She is living at home and has the summer off. She does not have a job and is in a protective environment. Should we wait until she has to make sacrifices both socially and academically to deal with this? Do we wait until she is in college or has a job that put stress on the either living with the deformity or the stress of the surgical recovery?
With a 25 degree met adductus angle and a 15 IM, the true 1st IM is closer to 25. Do I do a head procedure or base or tight rope? again, perhaps not this year, but maybe next.
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